the thoughts of a surgeon in the notorious province of mpumalanga, south africa. comments on the private and state sector. but mostly my personal journey through surgery.

Monday, January 18, 2010

in the dead of night

after having spoken about when you seem to know more than your consultant, i was reminded of another incident from my internship year where a colleague of mine taught me that sometimes it is best to do certain things under cover of darkness.

the patient (a sangoma) turned up at the surgery clinic one day. my colleague asked her what the problem was. without uttering a word she lifted up her shirt to expose her breasts. the left one had a massive tumour that had fungated through the skin probably some time ago. there was a large stinking cauliflower-like mass with central ulceration that caused a fist sized cavity right up to the chest wall. the smell was also remarkable. we couldn't help asking why the patient hadn't sought help earlier, especially seeing that she was supposed to be a so called traditional healer. i mean you didn't have to be a rocket scientist to know that that stinking monstrosity growing right through the chest was not supposed to be there. she simply said that it hadn't been painful, but now she had a cough.

my colleague knew what to do. she would refer the patient to the academic center in bloemfontein in the morning, probably for palliative radiotherapy. to make sure everything was up to date, she took a chest x-ray. it was so impressive she showed it to me. the breast cancer had grown right through the chest wall and had infiltrated the lung below. that is what caused the cough. it was a truly amazing case of neglected breast cancer.

then the cuban surgeon strolled in. this was the sort of thing you just didn't see in cuba. their health system is just too good for something like this to slip through. i suspect they don't have the sangoma problem we are burdened with so on the whole there will be less late stage sicknesses presenting. he was clearly astounded. then he said something that confused both my colleague and myself.

"put her on tomorrow morning's list for me to do a debridement." we looked at him in amazement. my colleague whipped out the x-ray, assuming that after seeing it no sane person would want to put a knife to that thing. i mean where would you stop cutting? in the lung? he looked at the x-ray casually but said nothing.

"you still want me to put her on your list tomorrow?" asked my colleague with more than just a hint of sarcasm in her voice.

"yes." we glanced at each other. maybe there was something we were missing. my colleague entered into a lively debate with him about the rationality of what he was demanding. anyway it was not my patient and i had other things to do so i left as the level of their discussion escalated. i did not envy her position in that she was being asked to do something she knew was not a good idea by any stretch of the imagination.

the next morning i ran into my colleague. she had a broad smile on her face and a somewhat mischievous glint in her eye. obviously the resolution of the matter had been to her liking.

"so," i asked, "did he finally see the light and drop his mad idea?"

"no." she said. the smile didn't falter.

"then what happened?"

"well i was on call last night. so as soon as the sun set and our illustrious consultant went home i bundled the patient into an ambulance and sent her off to the academic hospital. when he got to work this morning the patient was gone. there was nothing he could do." the smile took on an almost sinister look. i was impressed.

years later i employed a similar strategy, but maybe that is better left for another post?

18 comments:

You've mentioned the "cuban" surgeon a couple of times now, not in a good way. Was this a particular none-too-competent surgeon you worked with, or are the cuban surgeons as a class something less than optimal?

Also, you refer to the cuban health system as "too good for" that kind of neglect. My head is still spinning on that one.

why are there cubans in SA? its not a communist country is it? i thought you had plenty of medics trained in SA. maybe the really crap cubans go to SA. can we not hire a ship and transport them all to Haiti? i am sure there is plenty to keep them busy there

It's not the same Cuban doctor in every story. Cuba offers free medical school, so they get a lot of applicants. They send them all of the world to generate good will. For example, there are 200 Cuban doctors helping out in Haiti right now.

Yes, Cuba has a really good socialist health care system. If you need treatment, the government will pay for your treatment, no questions asked. Their main issue is that due to our half-century embargo it can be hard for them to get the supplies they need when they need it.

i am seriously worried that cuban doctors are sent out into the world to "generate good will". there are plenty well meaning generators of good will in the world already. when it comes to surgeons in particular: i dont care if he is as cross as a bag of weasles. but i want him to be competent. Bar Humbug to "good will"

shadowfax, interestingly enough these two stories refer to two different cuban surgeons. as with all things on my blog, the following is my opinion alone.

when the anc took over in 1994 they quickly mannaged to destroy public health in the periphery. i mentioned this in one or two of my very first posts when i was still full time in public service. once this had been accomplished they entered into an agreement with the cuban government to supply us with doctors. these doctors are specialists in their country but only get limited registration to work as senior medical officers in our country, specifically in their speciality. they do not measure up at all to south african specialists but they are pretty good in the capacity of medical officer. occasionally there is a problem like a general surgeon having absolutely no experience in thoracic surgery as demonstrated in my last post. the surgeon in this post was a bit young and inexperienced and therefore made a bad call.

the cuban health system is pretty good. they have a high ratio of doctors to population and therefore give a pretty thorough service. i think their population is also more inclined to seek western help before going to a sangoma and therefore things like fungating breast cancers that have infiltrated the lung are not at all ever seen. they also don't have people in their population that fall through the system because of lack of money.

anonymous, we don't have enough doctors and almost all our specialists move into private, thereby creating a shortage especially of specialists in public health. we are not a comunist country yet although the anc and the south african comunist party have an alliance, so watch this space.

havana, the cubans, as i said are not a patch on south african specialist, but they are better than nothing.

Hey Bongi! Great post...and good for your colleague, to stick to your guns and what you believe in. I thought your description of her breast lesion was incredibly detailed--a skill of your excellent writing. I cringed for her. Well done, bud!

I find it fascinating that the American comments on Cubans seem to tend towards the negative side. Why is that? Do you guys know alot about Cuba and Cubans or is it just because they're communists? Just asking.

scns for outsiders like us south africans we find it mildly amusing that america, the superpower is still stuck on something that happened in the '60's when the entire world has moved on. why doesn't america get over it and leave cuba alone?

we can't help admiring cuba and in this specific scenario, despising the bullying tactics of america. i mean the '60's is a very long time ago. the cold war is over and the rest of us are worried about global warming. get over it.

Each country has it's stuff. WWII veterans (an entire large country full) and their children to some extent. This is the age demographic that has over all others been consistently patriotic in the states for decades. They can be counted on to vote. As time marches on, people die, new ideas have a chance.

i am losing my sarcastic, sardonic edge. who knew that was even possible?

given the way my country, the united states, has politicized improvements to our health care delivery system? i absolutely can imagine myself with tumor-infested breasts and lungs, availing myself of "the system" only for final palliative care. frantic boat rides may soon reverse course, heading to cuba from southern u.s. climes...

anyway -- as a token non-medical person, i am dying to know... wait, let me rephrase that... please, sir, what would the cuban surgeon actually have done, do you know/think?

i confess to a fantasy that perhaps he wanted to plant some suggestion in her head... a ploy to play off her belief system.

as for cuba and traditional healers -- don't forget espiritistas or the santeros! still, you are right - in general, this is a population well supplied with preventive care and almost around the clock access to health care. i have heard that the notion of going to the emergency department (as is becoming all the rage here in the u.s.) is considered bizarre.

sigh.

i have long admired cuba's efforts in areas such as medicine, while abhoring the notion of a blockade being put on humanitarian supplies/equipment.

well, let me go browse and see what other *wonderful* things you have written!

Cuba is just a hot button item for a lot of Americans. It has been a controversy for so long that for many Americans there are nothing but emotions in the debate, no facts or proportionality. I don't know if there is an equal in another country, e.g., Algeria to French people of a certain age.

If you ever saw Michael Moore's "Sicko", he was being deliberately provocative by trying to show how Cuba's medical system was better than the U.S. in some ways. The world shrugs at the obvious, but that would make many Americans see spots. For the most part, the youngsters could not care less about Cuba, so the heat seems to be lessening.

the value of toilet mastectomy has a lot to do with skin closure. debriding into the lung, which is what would have happened here, is not a good idea.

mastectomy for the less advanced stage four is actually a good idea, but more for local control than survival. once again skin closure is the critical issue.

i'd be interested to see the reference you refer to.

also as a side note, cubans that i befriended, and there were quite a few, generally said that, because of the american embargo against their country, they generally studied out of somewhat outdated textbooks. they were usually quite excited to have access to the up to date books in south africa.

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the aim of this blog is to give insight into the mind of a particular surgeon, me. although every story is loosely based on fact, patients have been changed suitably to protect their identity. the opinions expressed are mine alone and are not meant to be considered medical advice or the opinion of any institution.